A New Perspective in Health Care: Inside or Outside

Robert C. Bowman, M.D. rcbowman@atsu.edu

Summary

Physicians with origins outside of concentrates, older age at graduation, trained outside of concentrations, and choosing family medicine all have lower probability of admission but when admitted have increased probability of most needed health access careers and locations.

What is required for understanding of most needed health access is the understanding of Inside and Outside. Those outside have 2 – 3 times greater health access career choices when they gain admission. This is boosted by 30% by older age at graduation. This also is multiplied by 2 or more times by choice of family medicine. A final boost of 1.5 to 2 times is provided by training focused on health access.

The usual approach is most exclusive in origin admitted for health access cut in half, then younger or normal age for 20% decrease in health access, then lack of family medicine choice for another 30 – 50% decrease, then most exclusive training for another 0.5 odds ratio cut in health access. ^{1, 2} See Tables on Complete Populations of Physicians

This is why a rural health access focused school such as Duluth with more normal in admission, training, and career choice has 64 times the rural primary care production (and retention) of a top 20 MCAT ranked school that admits, trains, and graduates most exclusively.

Inside or Outside of Physician Concentrations

Nearly all would accept the statement that rural populations and underserved populations are outside of concentrations of physicians. The perspective of inside and outside applies. However when top concentrations are considered, there are also marginal locations that have much less than the average physician concentrations. In fact, the United States divides into locations with much greater than the average of 280 physicians per 100,000 and physician concentrations of 60 to 150 per 100,000.

Although the focus of health access workforce has always been outside of concentrations using concentrations of income or people, it is actually easier to use Inside of Concentrations using a more direct approach, concentrations of physicians instead of people or income.

Inside of physician concentrations is the easiest definition to shape and makes the most sense. Physicians do not examine lack of physicians, health resources, or other physicians when choosing practice locations. They choose locations that have top support, top numbers of physicians, and physicians of their own specialty.

When coding patterns of distribution of physicians, the most logical approach is to code by concentrations of physicians. Physician concentrations are not reliably found in concentrations of income or people, but they are consistently found when physicians congregate together or as employees of medical schools, systems, clinics, or hospitals.

Coding has focused on income, geographic markers, and economics. Coding has also involved physicians, but has minimized coding of top concentrations of physicians. Common sense dictates that when physicians have top concentrations in one location, there will be shortages in other locations. Studies that capture factors associated with physician concentration also illustrate the reasons for shortages or those populations that are left outside of concentrations of physicians.

This is apparently hard for many to understand. This perspective is also difficult for some since the findings indicate such inequitable distributions of physicians with 65% of the US population left behind at least in distribution aspects. Also those inside of concentrations control the databases, the coding, the literature, medical education, graduate medical education, health policy, and the perspectives used in interpreting the results. Obviously with decades of failed health care, health policy, and health access, a new perspective is needed and Inside Versus Outside is a best practices choice (See Why Physician Workforce Needs New Tools).

Inside of physician concentrations is a practice location in 3400 zip codes in just 4% of the land area. The United States has over 75% of physicians inside of physician concentrations. These are locations that have top concentrations of physicians, income, people, professionals, and health resources. This 4% of the land area contains 70% of remaining internal medicine and pediatric primary care, 80 – 92% of specialists, and over 90% of clinical, research, graduate medical education, and medical education funding connected to physicians in 4% of the land area. Only 35% of the United States population is found inside of concentrations. Physician concentrations greatly exceed population concentrations in the Super Center and Major Center locations that have top concentrations. Once this is understood, the definitions of inside and outside of concentrations of physicians can enter perception. Only family practice forms escape top concentrations with 53 – 60% found outside. (See Physician Distribution by Concentration Coding)

The medical students from rural and from underserved origins also arise from outside of concentrations.

The medical students from most urban, highest income, professional or physician parents that were born, raised, educated, and trained in top concentrations for the first 30 years of life can also be understood as those consistently inside of concentrations from birth until they enter practice. This is not just a simple matter of more exclusive parent income levels and more exclusive most urban origins. The children born, raised, and trained in concentrations also have professional or dual professional parents, physician parents, the highest levels of social organization, birth and life experiences in counties with medical schools or other top concentrations of physicians, and highly specialized lifestyles and health care preferences. With the territory of being born, raised, educated, and trained in top concentrations away from most Americans comes a sad lack of awareness of people who are lower and middle income in America that are more normal and less exclusive. The division of Americans into a smaller top segment and an increasingly larger bottom segment also divides Americans into those less and less aware and those more and more painfully aware of the divisions. (See Framework of Experiential Place: Taxonomies, Theories, Themes)

Although physician workforce is commonly seen as inside and outside of concentrations using income or geographic terms, physician concentration is a much better marker of inside and outside. This is a direct measure more suitable for coding physicians that also encompasses concentrations of income (or poverty) as well as concentrations of people (or lack thereof). The Physician Distribution by Concentration coding system begins with the simple division of zip codes into locations with concentrations of physicians that have 75 or more physicians and locations that are outside of concentrations at less than 75 physicians.

Super Centers are zip codes with 200 or more physicians and are commonly medical school or major health system zip codes. Super Centers average 1100 physicians per 100,000 people or about 4 times the national average. Major Centers have 75 – 199 physicians at a zip code and average 400 physicians per 100,000. The locations outside of physician concentrations all have one-fourth to one-half of the national average physician concentration. Marginal Urban or Marginal Rural locations have less than 75 physicians and average or lower poverty. Marginal Urban locations have the lowest poverty levels and highest income levels of any practice locations. Marginal urban locations are a prime target for urgent care centers, Walgreens, CVS, and others due to convenient locations adjacent to top concentrations but are not representative of most needed health access. Some are in the process of becoming Super Centers and Major Centers. Urban Underserved or Rural Underserved locations with less than 75 physicians, poverty levels 19% or more, or a major federal shortage designation (whole county primary care, Community Health Center site, National Health Services Corps site). (See Physician Distribution by Concentration Coding)

Most needed health access clearly involves Marginal Rural, Rural Underserved, and Urban Underserved locations, but not all rural areas are most needed health access locations. Rural locations with 75 or more physicians are coded Major Centers or Super Centers and clearly have the top concentrations of physicians as well as the lower family practice and primary care percentages found consistently in concentrations of physicians. Cooperstown NY is isolated rural but the health care system could be transplanted to Manhattan and not be noticed as different, including medical education, graduate medical education, the most lines of funding, and the top reimbursement in each line.

Rural locations with less than 75 physicians is an appropriate marker of most needed health access and includes Marginal Rural and Rural Underserved locations that have only 80 – 120 Urban underserved locations have the lowest levels of physicians sharing 60 physicians per 100,000 with isolated rural underserved locations.

Also the family practice forms are also outside of concentrations of physicians. Family practice physicians and the non-physicians that practice (practice, not just train) in the broad generalist family practice mode are outside of physician concentrations.

The family practice mode distributes with 50 – 60% found in zip codes with 65% of the US population. Family practice physician assistants have 30% rural location and are the only PAs to have greater than average rural distribution. Family practice physician assistants have 6 – 7 times the Community Health Center location rates of PAs not in family practice. Declines from 60% to 20% entering family practice careers at graduation devastates PA most needed health access contributions.

Physician assistants and nurse practitioners once followed the Principles of Health Access³ with origins outside of concentrations, training outside of concentrations (decentralized, often with family physicians), family practice choice, older age graduates, and policy supportive of health access (and restrictive of practice location inside of concentrations). Now physician assistants have more and more exclusive origins and career intentions, train inside of concentrations, are less likely to begin in family practice careers and depart steadily in the years after graduation even during 1990s optimal policy (Larson and Hart),⁴ and contribute less and less with each class year and each passing year to primary care, rural, and underserved workforce. NPs and PAs departing family practice depart services to the 65% of the population outside of concentrations and the 70% of the elderly that share the same locations for the 3400 zip codes with top concentrations of physicians that also have top concentrations of non-physicians. Actual primary care contributions of non-physicians have remained as flat as primary care and family practice contributions of physicians. (see 1960 – 2020 Physicians and Non-Physician Numbers by Specialty or Primary Care Divisions)

Solutions for Health Access

When structuring true recovery of health access primary care, the Principles of Health Access³ must be followed. There are a number of Steps to Health Access⁵ that must be addressed simultaneously.

Those prepared birth to admission must represent the 65% of Americans that are outside of concentrations. Those admitted must also include sufficient physicians and non-physicians that are from the 65% of American populations outside of concentrations. Training must be health access in focus and there has been more than enough proof that current training does not have this focus nor is it likely to have this focus anytime in the next decades. A Specific Health Access Medical School Training Is Required.⁶ Training must result in a pure or near pure strain of family practice that remains in family practice broad generalist mode. Only family physicians meet the required elements to facilitate health access recovery at the current time and all remaining primary care will need protection from further destruction under current policy. If other sources require 15 or more years of broad generalist mode as a condition of admission, they can approach the consistent record of family physicians with 85% remaining in family practice and primary care, 20% rural or above for all class years, and 14% underserved and above for all class years. Short of a 15 year commitment, it is unreasonable to expect any other source to be a part of primary care or health access recovery. Given the facts, it is actually deception to promote internal medicine, nurse practitioner, or physician assistants as solutions with decades of departures from primary care, rural, and underserved locations with each class year and each year after graduation.

Health access recovery demands retention in the broad generalist family practice mode at 90% or above, retention in primary care at 90% or above, retention in active practice for a career at 90% or above, top volume of primary care delivery at 90% or above compared to a family physician, top retention in underserved locations at least 11% or at least 50% above the current 7 - 8% level, top retention in rural locations at 15% levels or over 50% above the current 9 – 10%, and distribution at 50% or above to the 65% of the US population in 29,000 zip codes that has only 20 – 25% of physicians and non-physicians. Health access recovery requires that 100% of graduates be able to stand on their own in practice even in facilities with the lowest support and working with personnel that have the least support and are often the least experienced and lowest paid. The role requires the ability to assume a wide range of administrative, managerial, mental health, women’s health, hospital, emergent, procedural, community, and continuity primary care roles.

The choices include family medicine residency training or making some other practitioner just like family physicians. Even family medicine residency training would need to be enhanced but such training is far ahead of any other type of training at the current time. Why 5000 More FM Grads What Recovery Looks Like (But Will Take Decades More)

By the way, when the United States reaches 12,000 – 13,000 annual graduates that meet these criteria for their entire careers (or half of the current 28,000 IM, NP, PA, PD, and FM) or one third of the 45,000 in 2050 with expansions), it will still take 35 years or a generation (age 30 - 65) of class years of graduates to restore basic health access and primary care in America. This is because the US leaders in health care and US political leaders fell off the previous health access recovery plan in financial support, in workforce support, and in infrastructure design in the 1980s after quadrupling primary care numbers from 1970 to 1980 and rebuilding health care infrastructure in lower and middle income America (rural, underserved, elderly). See the Graphics of Beginning and Falling Away. Also this graphic illustrates how the United States can delay recovery with generic physician expansion, a focus on more internal medicine or a focus on NP and PA expansion. These are methods that fail to result in increases in primary care.

Had the United States stayed on course after 1980 with permanent primary care with sufficient primary care support and for the lower and middle income populations most dependent upon primary care, the United States would have had recovery of health access and primary care in 2005 and even if production was taken away by policy as in the past decade, the lasting primary care due to choice of a permanent design would have endured future decades. Now there is little that can be done for the current generations. There is only recovery for future generations necessitated because past generations failed. If the United States gears up by the class of 2020 for the required 12,000 or more permanent efficient, and effective primary care, it will still be past 2050 for recovery.

For those still failing to grasp the concepts regarding primary care, destruction, and recovery - please review the graphic

To Review

Physicians with origins inside of concentrations, trained inside of top concentrations, and not choosing family practice are most likely to gain admission and are most likely to be found inside of top concentrations in practice locations. Those most exclusive have the most biomedical focus, the most exclusive careers, the most focus on science and technology, and the least focus on people.^{2, 7, 8}

All that is needed to concentrate physicians is to continue the current pattern of more exclusive gaining admission, more exclusive health professional education (physician and non-physician), steady decline in family medicine choice (or remaining in family practice for PA and NP), and steady increases in the health funding going to 4% of the land area in top concentrations as in the past century.

What is needed to restore health access in America is departures from current policies in all fronts with movement steadily toward more normal in admission, more normal in career choice, and more normal in health policy distributions of funding with lower and middle income population health care and primary care for lower and middle income populations the focus of recovery. This is also a true method of recovery that avoids the distortions of the current method. This true method of recovery avoids the continued pattern of more funding going to a smaller segment of the US population that already has top concentrations.

This is not about a political system change, a political party, or an economic system change. It is about better balance in the United States for a more efficient and effective nation that will do better overall both inside the United States and in dealing with those outside of the United States. In the purest sense, what is required is better birth to age 6 in America. Those that want to argue against children and a better future for all in the United States better think twice about what is truly important and what will happen to all in the United States if each passing year the basic child in America does not become slightly but steadily better and better.

Ultimately health care costs, quality, and access all depend upon a better American child making better decisions and becoming a better student, employee, citizen, health care provider, administrator, and leader.

Other Data Sources include AAMC, AMA, AAFP, AANP, and AAPA.

Slide Show Presentation using the above text at request from rcbowman@atsu.edu

1. Bowman RC. They really do go. Rural Remote Health. Jul-Sep 2008;8(3):1035.

2. Bowman RC. The Basic Logistic Regression Tables: Taxonomy, Themes, Theories of Experiential Place and Basic Health Access. http://www.ruralmedicaleducation.org/basichealthaccess/taxonomies_themes_theories.htm.

3. Bowman RC. Principles of Basic Health Access. www.ruralmedicaleducation.org/basichealthaccess/principles_summary_points.htm.

4. Larson E, Hart LG. Geographic and Demographic Dimensions of the Adoption of a Health Workforce Innovation: Physician Assistants in the United States, 1967-2000 Working Paper #105 http://depts.washington.edu/uwrhrc/uploads/CHWSWP105.pdf. Accessed October 2007.

5. Bowman RC. Steps to Basic Health Access. http://www.ruralmedicaleducation.org/basichealthaccess/Steps_To_Health_Access.htm.

6. Bowman RC. The Health Access Medical School. http://www.ruralmedicaleducation.org/basichealthaccess/Health_Access_Medical_School.htm.

7. Bowman RC. Older Age Graduates and Most Needed Health Access. http://www.ruralmedicaleducation.org/basichealthaccess/Older_Age_and_Health_Access.htm.

8. Bowman RC. Basic Health Access Concepts That Must Be Understood. http://www.ruralmedicaleducation.org/basichealthaccess/Basic_Access_Concepts_to_Review.htm.